Family and/or peer support should also be encouraged in any prescribed weight management program. Our experience with the men’s program GutBusters suggests a female partner will generally support a male partner’s program, but this is not necessarily the case in reverse.20 Peer support can also be encouraged through pairing the patient with a partner (buddy system). The use of group education, shared medical appointments and programmed shared medical appointments is another way to use peer support to assist the treating clinician.21
5. Consider the environmental influences on the patient
The environment in which we live and work includes elements of various types and levels that can influence a patient’s risk of and response to weight gain and loss. Elements of the environment are often characterised as physical, political, economic and sociocultural, which operate either at a macro or micro level to influence components of energy balance.
At the clinical level, it’s difficult to deal with many of these environmental influences, particularly at the macro-environmental level. But it is feasible and necessary to consider the micro-environmental elements (e.g. home, schools, neighbourhood), although this area is often overlooked due to the difficulty and time-consuming nature of dealing with these issues. Still, it is possible to mitigate the potential negative influence of the micro-environment with a range of simple strategies to change dietary or activity responses that may contribute to an excess or positive energy balance (Box 3).
6. Realise the limitations of counting calories
Self-weighing and self-monitoring of diet, activity and other behaviours has consistently been linked with better weight-management outcomes.22 In recent times there has been an explosion of electronic applications that promise to improve the ease, completeness and interpretation of this monitoring process, such as activity trackers like Fitbits and heart rate monitors, although their utility over simpler recording techniques remains unclear.23 Many of these programs claim to calculate total calorie intake and predict the amount and rate of weight loss. However, calorie counting should be viewed with scepticism. The claimed accuracy of calorie counts of these programs is greatly exaggerated, and the limitations of calorie-intake data make calorie counting less meaningful in terms of weight management.
The calorie (or kilojoule) content of food is usually seen as the amount of energy stored within that food and is accurately measured by burning the food in a calorimeter or more usually estimated from the constituent macronutrient composition. It is often assumed that each calorie consumed has the same contribution to energy balance regardless of how the food is consumed or who consumes it. However, individual differences in metabolic rate, the compensation of the microbiome in the gut, digestion, thermogenesis and a range of other factors can lead to small but meaningful differences in how much of that calorie is available to an individual.24 This can lead to the same calorie surplus or deficit resulting in different weight gain or weight loss outcomes in similar individuals. Thus, strict calorie counting is misleading and best avoided.
Another implication of this observation is that although it remains important to encourage reduced energy intake ‘volume’ and increased energy expenditure ‘volume’ (as set out in points 1 and 2), the means of achieving this objective and the ‘volume’ of energy associated with the same change in behaviour may vary between individuals (or even within individuals). Some experimenting will be required to determine the extent of behaviour change required to achieved the desired weight loss for each individual patient.
7. Avoid fad diets and single-option programs
It has been well established that any diet that conforms to principle 1 above (where energy expenditure exceeds energy intake) can achieve at least short-term weight loss, but that the best ‘diet’ (more properly called an ‘eating plan’) for any one individual is one that can be adhered to over the long term.25 Fad diets and single-option weight-loss programs as promoted in common diet or weight-loss books, as well as an over-reliance on calorie counting alone, rarely meet these criteria and should be avoided.24 It is best to devise a long-term eating plan that is not overly rigid and that can be rationally adhered to even with diversions along the way. Patients who require strict instructions may not welcome this approach, but it is likely to be best maintained over the long term in the current environment.
8. Focus on weight-loss maintenance as much, or more than, initial loss
Although short-term weight loss is relatively easy to achieve, maintenance at the lower weight is more problematic. As pointed out above, evolutionary selective pressures favour the storage of excess energy over the potential survival threat of undefended weight loss. Hence, it is well established that adaptation processes, such as changes in the gut hormone levels or gut microbiota, may result in increased hunger or more efficient ‘food harvesting’ that promotes weight regain for years after a major weight loss.